Demographic Data for Development Decisionmaking: Case Studies From Ethiopia and Uganda

Analyzes the lack of demographic and socioeconomic data, limited access to and use of existing data, and insufficient demand for their application in policy making and resource allocation. Makes recommendations for greater access, demand, and use of data

“I feel good when I drink”—detecting childhood-onset alcohol abuse and dependence in a Ugandan community trial cohort

Background Alcohol, substance use, and mental health disorders constitute major public health issues worldwide, including in low income and lower middle-income countries, and early initiation of use is an important predictor for developing substance use disorders in later life. This study reports on the existence of childhood alcohol abuse and dependence in a sub-study of a trial cohort in Eastern Uganda. Methods The project SeeTheChild—Mental Child Health in Uganda (STC) included a sub-study of the Ugandan site of the study PROMISE SB: Saving Brains in Uganda and Burkina Faso. PROMISE SB was a follow-up study of a trial birth cohort (PROMISE EBF) that estimated the effect that peer counselling for exclusive breast-feeding had on the children’s cognitive functioning and mental health once they reached 5–8 years of age. The STC sub-study (N = 148) used the diagnostic tool MINI-KID to assess mental health conditions in children who scored medium and high (≥ 14) on the Strengths and Difficulties Questionnaire (SDQ) in the PROMISE SB cohort N = (119/148; 80.4%). Another 29/148 (19.6%) were recruited from the PROMISE SB cohort as a comparator with low SDQ scores (< 14). Additionally, the open-ended questions in the diagnostic history were analysed. The MINI-KID comprised diagnostic questions on alcohol abuse and dependence, and descriptive data from the sub-study are presented in this paper. Results A total of 11/148 (7.4%) children scored positive for alcohol abuse and dependence in this study, 10 of whom had high SDQ scores (≥ 14). The 10 children with SDQ-scores ≥ 14 had a variety of mental health comorbidities of which suicidality 3/10 (30.0%) and separation anxiety disorder 5/10 (50.0%) were the most common. The one child with an SDQ score below 14 did not have any comorbidities. Access to homemade brew, carer’s knowledge of the drinking, and difficult household circumstances were issues expressed in the children’s diagnostic histories. Conclusions The discovery of alcohol abuse and dependence among 5–8 year olds in clinical interviews from a community based trial cohort was unexpected, and we recommend continued research and increased awareness of these conditions in this age group. Trial registration Trial registration for PROMISE SB: Saving Brains in Uganda and Burkina Faso: Clinicaltrials.gov (NCT01882335), 20 June 2013. Regrettably, there was a 1 month delay in the registration compared to the commenced re-inclusion in the follow-up study: https://clinicaltrials.gov/ct2/show/NCT01882335?term=saving+brains&draw=2&rank=1publishedVersio

Access to Child and Adolescent Mental Health services in Uganda: Investigating the role of Primary Health Care and Traditional Healers

Introduction: Up to 20% of children and adolescents globally suffer from a debilitating mental illness and up to 50% of adult mental illness begins in adolescence. Early detection and management of Child and Adolescent Mental Health (CAMH) disorders reduces the likelihood of long term ill-health and minimizes stress on individuals, families, communities and health systems. Robust health systems are required for optimizing CAMH. However, the coverage of CAMH services in most low-income and middle-income countries (LMIC) is low and health system responses to CAMH have been weak. To increase the coverage of CAMH services, the WHO and others recommend the integration of CAMH into primary health care (PHC) in LMIC. The Mental Health Gap Action Program (mhGAP) and intervention guide (IG) were developed for this purpose. To increase entry into CAMH systems, recent studies recommend collaboration between traditional healers and mental health professionals. The main objective of this research was to investigate access to mental health services for children and adolescents in Uganda through PHC workers and traditional healers. Methods: This concurrent mixed-methods study was conducted in two districts of Eastern Uganda. The qualitative studies utilized key informant interviews with all public officials (n=7) responsible for supervision of CAMH services (Paper I) and in-depth interviews with 20 purposively selected traditional healers (Paper II). The quantitative studies comprised a pre-test/post-test study (Paper III) nested within a pragmatic randomized controlled trial (RCT). The quantitative sub-studies included nurses, midwives and clinical officers who provide PHC services to children and adolescents in level-3 health centers (HC III) in both districts, and who had not previously undergone CAMH training. The RCT (paper IV) intervention consisted of 1) training 36 PHC providers from 18 randomly selected HC III for five days using a curriculum based on the mhGAP- IG version 1.0; and 2) provision of training handouts as job-aids. The RCT compared the proportion of intervention (n=18) to control (n=18) clinics with a non-epilepsy CAMH diagnosis recorded in the clinic registries over three consecutive months following training. Qualitative data were analysed using thematic analysis. Analysis in paper III was based on two-tailed t-tests to assess differences in mean pre-test and post-test scores between the cadres; hierarchical linear regression tested the association between cadre and post test scores; and logistic regression evaluated the relationship between cadre and knowledge gain at three pre-determined cut off points. Fisher’s exact test and logistic regression based on Intention to Treat principles were applied for paper IV. The trial is registered at clinicaltrials.gov registration NCT02552056. Results: Existing CAMH national laws and policies were found to be sufficient. Insufficient public financing for CAMH services and inadequate quality and quantity of CAMH services was cited by all health managers. CAMH services at lower health centers and integration of mental health and CAMH into other health sector services was absent. The health workforce was insufficient in number and skills. Epistemologies of mental illness in children and adolescents were shared between traditional healers and bio-medical providers, but traditional healers had limited interactions with the biomedical health system for mental illness. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them (paper II). Thirty-three participants completed both pre-and post-tests. There was an improvement in the mean scores from pre- to post-test for both clinical officers (20% change) and nurse/midwives (18% change). Clinical officers had significantly higher mean test scores than nurses and midwives (p < 0.05) but cadre was not significantly associated with improvement in CAMH knowledge at three cut-off points of knowledge gain: 10% (AOR 0.08; 95 CI [0.01, 1.19]; p = 0.066), 15% (AOR 0.16; 95% CI [0.01, 2.21]; p = 0.170), or 25% (AOR 0.13; 95% CI [0.01, 1.74]; p = 0.122) levels. The proportion of clinics with a non-epilepsy CAMH diagnosis prior to training was 27·7% (10/36, similar between study arms). Following training, nearly two thirds (63·8%, 23/36) of all clinics identified and recorded at least one nonepilepsy CAMH diagnosis from 40,692 clinic visits of patients aged 1-18 recorded.. Training did not significantly improve intervention clinics’ nonepilepsy CAMH diagnosis (13/18, 72·2%) relative to the control (7/18, 38·9%) arm, p=0·092. The odds of identifying and recording a non-epilepsy CAMH diagnosis were 2·5 times higher in the intervention than control arms at the end of 3 months of follow-up (adj.OR 2·48; 95% CI [1·31, 4·68]; p=0·005). Conclusion: The CAMH system in Uganda is weak. CAMH workforce development to address the human resource gap; and increased integration of CAMH into primary health care and other sectors are suggestions for improving the availability and quality of CAMH services. Collaboration between traditional healers and biomedical providers is possible but is undermined by a prevailing mutual mistrust and competition between traditional healers and clinicians, calling for the implementation of strategies that harness the complementarity of traditional and biomedical providers. PHC providers are important actors in improving access to CAMH services within Uganda’s CAMH system. PHC provider training using mhGAP-IG v1 improves CAMH knowledge; and learning outcomes are independent on the cadre of the provider being trained. Therefore, an option for integrating CAMH into PHC in Uganda is to proceed without cadre differentiation. However, training alone does not result in significant improvements in clinics’ identification and reporting of nonepilepsy CAMH cases. Further task-sharing studies integrating CAMH into a larger sample of PHC clinics are suggested, including a community mobilization component in the intervention to improve CAMH clinic attendance

“We are like co-wives”: Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda

Background: Early identification and management of mental illness in childhood and adolescence helps to avert debilitating mental illness in adulthood but the attention given to Child and Adolescent Mental Health (CAMH) has until recently been low. Traditional healers are often consulted by patients with mental illness and in Uganda, up to 60% of patients attending traditional healers have moderate to severe mental illness. Poor access to CAMH care in Uganda creates a treatment gap that could be met through enhanced collaboration between traditional healers and biomedical health systems. The aim of this study was to explore traditional healers’ views on their collaboration with biomedical health systems so as to inform the implementation of strategies to improve access to CAMH services in Uganda. Methods: In-depth interviews with 20 purposively selected traditional healers were conducted in November 2015. A semi-structured interview guide was used to explore: 1) The experiences of traditional healers with mental illhealth in children and adolescents; 2) their willingness to collaborate with the formal health system; and 3) their perception of clinicians’ willingness to collaborate with them. Interviews were conducted in local languages and tape recorded. Data were analysed using thematic analysis. Results: Traditional healers described several experiences managing children and adolescents with mental illness, which they ascribed to spiritual and physical causes. The spiritual explanations were a consequence of unhappy ancestral spirits, modern religions and witchcraft, while physical causes mentioned included substance abuse and fevers. No traditional healer had received a patient referred to them from a medical clinic although all had referred patients to clinics for non-mental health reasons. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies in alleviating mental suffering. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them. Conclusion: Potential for collaboration between traditional healers and biomedical health systems for improving access to CAMH services in Uganda exists, but is undermined by mutual mistrust and competition between traditional healers and clinicians

“We are like co-wives”: Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda

Abstract Background Early identification and management of mental illness in childhood and adolescence helps to avert debilitating mental illness in adulthood but the attention given to Child and Adolescent Mental Health (CAMH) has until recently been low. Traditional healers are often consulted by patients with mental illness and in Uganda, up to 60% of patients attending traditional healers have moderate to severe mental illness. Poor access to CAMH care in Uganda creates a treatment gap that could be met through enhanced collaboration between traditional healers and biomedical health systems. The aim of this study was to explore traditional healers’ views on their collaboration with biomedical health systems so as to inform the implementation of strategies to improve access to CAMH services in Uganda. Methods In-depth interviews with 20 purposively selected traditional healers were conducted in November 2015. A semi-structured interview guide was used to explore: 1) The experiences of traditional healers with mental ill-health in children and adolescents; 2) their willingness to collaborate with the formal health system; and 3) their perception of clinicians’ willingness to collaborate with them. Interviews were conducted in local languages and tape recorded. Data were analysed using thematic analysis. Results Traditional healers described several experiences managing children and adolescents with mental illness, which they ascribed to spiritual and physical causes. The spiritual explanations were a consequence of unhappy ancestral spirits, modern religions and witchcraft, while physical causes mentioned included substance abuse and fevers. No traditional healer had received a patient referred to them from a medical clinic although all had referred patients to clinics for non-mental health reasons. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies in alleviating mental suffering. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them. Conclusion Potential for collaboration between traditional healers and biomedical health systems for improving access to CAMH services in Uganda exists, but is undermined by mutual mistrust and competition between traditional healers and clinicians

Pathways to medical abortion self-use (MASU): results from a cross-sectional survey of women’s experiences in Kenya and Uganda

Abstract Background In Kenya and Uganda, unsafe abortions are a leading cause of maternal mortality. The new WHO policy guidelines on the safe termination of pregnancies up to 9 weeks lack information on women’s experiences with self-administered medical abortion (MA), impeding the development of interventions to increase MA use. This study aimed to comprehend women’s experiences with MA in Kenyan and Ugandan pharmacies. Methods A cross-sectional mixed-methods survey utilized data from medical registers in 71 purposefully identified pharmacies and clinics dispensing MA drugs between September and October 2021. Forty women who were MA users participated in focus group discussions. The main outcome variables were: sources of MA information, costs of MA services, complications from MA, pain management, follow-up rates, and use of post-MA contraception. Quantitative data were analyzed using Stata 15, while qualitative thematic analysis was conducted using Dedoose qualitative analysis software. Results 73.6% of 2,366 women got an MA, both in Kenya (79%) and Uganda (21%). Most (59.1%) were walk-in clients. Kenya had significantly more women referred for MA (49.9%) than Uganda (10.1%) (p 0.05). Friends and family members were the main sources of MA information. The median cost of MA was USD 18 (IQR 10–60.5) in Kenya and USD 4.2 (IQR 2–12) in Uganda. Most MA clients received pain management (89.6%), were followed up (81%), and received post-MA contraception (97.6%). Qualitative results indicated a lack of medicines, high costs of MA, complications, stigma, and inadequate training of providers as barriers to MA use. Conclusions and recommendations Communities are a valuable information resource for MA, but only if they have access to the right information. A relatively weak health referral system in Uganda highlights the importance of pharmacies and clinicians collaborating to support clients’ abortion needs and contraceptive use after medical abortion (MA). Low client follow-up rates show how important it is to make sure pharmacy technicians know how to give MA correctly. Finally, it is crucial to strengthen the supply chain for MA products in order to eliminate cost barriers to access

Integrating Family Planning and HIV Services at the Community Level: Formative Assessment with Village Health Teams in Uganda

Little is known on integrating HIV and family planning (FP) services in community settings. Using a cluster randomized controlled design, we conducted a formative assessment in two districts in Uganda where community health workers, called VHTs, already offered FP. Thirty-six trained VHTs also provided HIV testing and counseling (HTC) during the intervention. We surveyed all 36 VHTs and 256 FP clients, and reviewed service statistics. In the intervention group, VHTs tested 80% of surveyed clients for HIV, including 76% they already saw for FP and 22% who first came to them for HTC before receiving FP. Comparing clients‘ experiences in the intervention and control groups, adding HTC does not appear to have negatively affected FP service quality. VHTs reported more monthly clients, but rated their workload as easy to manage. This integrated model seems feasible and beneficial for both VHTs and clients, while not resulting in any negative effects. This study was registered with ClinicalTrials.gov, number [NCT02244398].  Keywords: family planning, HIV, community health workers, integration, Uganda Peu d‘informations sont disponibles sur l'intégration des services de planification familiale (PF) et du VIH dans les milieux communautaires. En utilisant un plan randomisé contrôlé par grappes, nous avons mené une évaluation formative dans deux districts en Ouganda dans lesquels les agents de santé communautaire qui sont appelés VHT offraient déjà des services de PF. Trente-six VHT formés ont également fourni des services de conseil et dépistage du VIH (CDV). Nous avons enquêté les 36 ASC et 256 clientes PF, et nous avons examiné les statistiques sur les services. Dans le groupe d'intervention, les VHT ont testé 80% des clients enquêtées pour le VIH, y compris 76% que les VHT voyaient déjà pour la PF et 22% qui sont d‘abord venus pour le CDV avant avant de recevoir la PF. En comparant les expériences des clientes dans les groupes avec et sans intervention, l‘ajout du CDV ne semble pas avoir affecté négativement la qualité des services PF. Les VHT ont signalé plus de clients mensuellement, mais ont évalué leur charge de travail comme étant aussi facile à gérer. Ce modèle intégré semble faisable et bénéfique pour les VHT et les clients, et sans entraîner d‘effet négatif. Cette étude a été enregistrée auprès de ClinicalTrials.gov, numéro [NCT02244398].Mots clés: planification familiale, VIH, agents de santé communautaires, intégration, Ougand

Integrating family planning and HIV services at the community level: formative assessment with village health teams in Uganda

Little is known on integrating HIV and family planning (FP) services in community settings. Using a cluster randomized controlled design, we conducted a formative assessment in two districts in Uganda where community health workers, called VHTs, already offered FP. Thirty-six trained VHTs also provided HIV testing and counseling (HTC) during the intervention. We surveyed all 36 VHTs and 256 FP clients, and reviewed service statistics. In the intervention group, VHTs tested 80% of surveyed clients for HIV, including 76% they already saw for FP and 22% who first came to them for HTC before receiving FP. Comparing clients‘ experiences in the intervention and control groups, adding HTC does not appear to have negatively affected FP service quality. VHTs reported more monthly clients, but rated their workload as easy to manage. This integrated model seems feasible and beneficial for both VHTs and clients, while not resulting in any negative effects. This study was registered with ClinicalTrials.gov, number [NCT02244398].Keywords: family planning, HIV, community health workers, integration, Ugand

Health managers’ views on the status of national and decentralized health systems for child and adolescent mental health in Uganda: a qualitative study

Background: Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15–30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective. Methods: Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes. Results: Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning. Conclusion: Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent

Does mhGAP training of primary health care providers improve the identification of child- and adolescent mental, neurological or substance use disorders? Results from a randomized controlled trial in Uganda

Background. Integrating child and adolescent mental health (CAMH) into primary health care (PHC) using the WHO mental health gap action program (mhGAP) is recommended for closing a mental health treatment gap in low- and middle- income countries, but PHC providers have limited ability to detect CAMH disorders.We aimed to evaluate the effect of PHC provider mhGAP training on CAMH disorder identification in Eastern Uganda. Methods. Thirty-six PHC clinics participated in a randomized controlled trial which compared the proportion of intervention (n = 18) to control (n = 18) clinics with a non-epilepsy CAMH diagnosis over 3 consecutive months following mhGAP-oriented CAMH training. Fisher’s exact test and logistic regression based on intention to treat principles were applied. (clinicaltrials.gov registration NCT02552056). Results. Nearly two thirds (63.8%, 23/36) of all clinics identified and recorded at least one non-epilepsy CAMH diagnosis from 40 692 clinic visits of patients aged 1–18 recorded over 4 months. The proportion of clinics with a non-epilepsy CAMH diagnosis prior to training was 27.7% (10/36, similar between study arms). Training did not significantly improve intervention clinics’ non-epilepsy CAMH diagnosis (13/18, 72.2%) relative to the control (7/18, 38.9%) arm, p = 0.092. The odds of identifying and recording a non-epilepsy CAMH diagnosis were 2.5 times higher in the intervention than control arms at the end of 3 months of follow-up [adj.OR 2.48; 95% CI (1.31–4.68); p = 0.005]. Conclusion. In this setting, mhGAP CAMH training of PHC providers increases PHC clinics’ identification and reporting of non-epilepsy CAMH cases but this increase did not reach statistical significance